Physician Accountability Chain

slug: physician_accountability_chain element_type: RULE mutability: MUTABLE inline: true current_version: 0 status: seed-draft contentURI: null

When AI participates in a clinical pathway, the patient's medical record must reflect an unbroken accountability chain:

1. Which AI tool participated. Vendor, model identifier, version, deployment context.
2. What it produced. The suggestion, score, flag, or finding it returned, captured verbatim with its uncertainty / confidence indication.
3. What the physician did with it. Accepted, modified, or rejected — and, if rejected or modified, a brief clinical reason.
4. Who the accountable physician is. Named, licensed, signed.

The chain is a record requirement, not a workflow requirement: it does not prescribe how the physician must interact with the AI, only that the interaction is documented in a form that allows after-the-fact reconstruction.

The accountable physician is the licensed counterparty for the clinical decision. Their accountability is not transferred to the AI vendor by virtue of having used the tool.

Status

seed-draft · current_version: 0. Placeholder. The exact field-set, retention period, and audit-access rules are for the domain author to specify.

Why this rule

01-human-in-the-loop-authority requires that AI is adjunct, not authority. Without an accountability-chain record, that requirement is unenforceable in practice — there is no trail by which to reconstruct who decided what and why.

This is the operational counterpart to the principle: the rule that turns "physician decides" into a thing you can audit.

Reasoning trail

• Aligns with classical malpractice doctrine on the accountable physician.
• Aligns with 01-human-in-the-loop-authority (PRINCIPLE) — operationalizes its requirement #2.
• Aligns with federation kernel transparency IMMUTABLE applied at the per-encounter level.
• Anticipates the audit needs of payors, regulators, and (rarely but importantly) malpractice litigation — the chain is what makes the claim "the physician decided" defensible.

Open questions for the domain author

• Is the chain part of the standard record schema (HL7 / FHIR), or a parallel log? The implementation cost differs sharply.
• What is the retention period? Suggested floor: the malpractice statute of limitations in the deployment jurisdiction.
• Who can request the audit — the patient, the physician, the institution, the regulator? At what scope?

Related elements

• 01-human-in-the-loop-authority (PRINCIPLE) — the principle this rule operationalizes
• clinical-decision (TERM) — the activity being recorded
• physician-irreducible (TERM) — what the chain protects
• algorithm-disclosure-to-patient (RULE) — patient-facing counterpart

Awaiting domain author

Open the conversation at leviathan.life/forum/medicine.